Welcome to the Feline
Diabetes Message Board, the group you never wanted to
join. If your cat has just been diagnosed, you probably have lots
of questions. This is a support group of cat-loving
amateurs; we're not experts, but among us we've accumulated
much experience and information about feline diabetes. This
FAQ contains information on some of the commonly asked questions
by newcomers (or questions which they should ask) but if you're unclear
on anything, or just need some tender loving care right now, please
post! We've all been where you are now.

Q1.1.
Help! My cat was just diagnosed!
What do I do?
Q1.2. Many of the cats here seem to have problems. Is my
cat doomed to a poor quality of life?
Q1.3. I don't understand all the terminology here.
Q1.4. What is hypoglycemia, and how do I handle it?
Q1.5. What treatment will my vet propose?
Q1.6. What is the goal of treatment?
Q1.7. Where can I find a vet who is knowledgeable about diabetes?
Q1.8. How can I find other people with diabetic cats in my area?
Q1.9. I can't afford to treat my cat. What should I do?

Q2.1. Can I
give oral medication instead of insulin?
Q2.2. Can I control
this with herbs or something instead of insulin?
Q2.3. What should I
feed my cat?
Q2.4. Can I free-feed my cat?
Q2.5. My cat doesn't like / I can't afford the expensive
prescription food. Is there any less expensive substitute?
Q2.6. How much should I feed
my cat?

Q3.1. What
kinds of insulin are there?
Q3.2. Where can I get PZI insulin?
Q3.3. What can I expect to pay for PZI insulin?
Q3.4. What kind of syringe should I use?
Q3.5. Do I need a prescription for insulin or syringes?
Q3.6. Can I reuse syringes?
Q3.7. How do I dispose of used needles?
Q3.8. My cat hates getting his shot. Now what?
Q3.9. How long does a bottle of insulin last?
Q3.10. Sometimes I can't be home to give one of my cat's shots;
is it okay to
give it late or early?
Q3.11. How much insulin should my cat be getting?

Q4.1. How
can I monitor how well the insulin is
working?
Q4.2. What kind of glucometer should I get?
Q4.3. How often should my cat's glucose
levels be tested?
Q4.4. My cat's pre-shot level was way below the usual
value. Should
I give the injection?
Q4.5. I'm not from the United States, and I don't understand your
units of measurement. My cat couldn't have a blood glucose of 300
even if you
soaked her in honey for a week.
Q4.6. I'm following
the instructions faithfully, but I still can't get
blood from my cat's ear.
Q4.7. My cat has been off of insulin for several days, and I'm
getting glucose readings in the 40s and 50s (2.2-3.3 mmol/L).
Should I treat him for hypoglycemia?
Q4.8. Are there other signs besides blood glucose that I
can monitor at home?
Q4.9. I'm interested in home-testing, but my vet won't let me.
What should I do?

Q6.1. What is
regulation?
Q6.2. Which definition of regulation should be my
goal?
Q6.3. How do I achieve regulation?
Q6.4. My cat has been on insulin for a while and her diabetes is
still out of control. Why can’t I regulate her?
Q6.5. What is tight regulation?
Q6.6. Is remission possible?
Q6.7. I just can't get my cat's glucose into regulation range --
is he doomed?

Q7.1. My
cat is walking funny / weak in the hind legs
/ not jumping well. Is this related?
Q7.2. My cat has kidney failure. How do I manage this as
well?
Q7.3. My cat has asthma; how can I avoid using steroids?
Q7.4. I can't get my cat to eat! What should I do?

1.
GENERAL

Q1.1. Help!
My cat was just diagnosed! What do
I do?

A1.1. Steve &
Jock recommend the following sites to help you get
started learning about feline diabetes:

Read, read, read!
Information is your best health-care
tool in managing your cat's diabetes. And ask here if you have
any questions or anything is
unclear.

Q1.2. Many of the
cats here seem to have problems. Is
my cat doomed to a poor quality of life?

A1.2. People tend
to post
here when they are having problems. Most diabetic cats
are doing just fine, so their owners tend to stay quiet. Diabetes
is highly treatable. Diabetic cats who are well regulated can live
normal lifespans with excellent quality of life, and tend to die of
other ailments of old age, rather than from diabetes. See Gorbzilla's Sugarcat
Journal for some inspiring stories of our cats' post-diagnosis
quality of life.

A1.4. Your
vet should have warned you about hypoglycemia, which
is dangerously low blood sugar brought on by too much insulin.
Hypoglycemia can kill your cat or cause blindness or other permanent
damage, so you must always be on the alert for the symptoms. Read
the hypoglycemia
page at Pets with Diabetes to familiarize yourself
with the problem. Then print out Melissa & Popcorn's hypoglycemia
pageand post it on your refrigerator, because hypoglycemia
can come on suddenly, and you don't want
to be running around trying to find this information.
You should always have a bottle of Karo or other sugar syrup handy in
your cupboard.

Q1.5. What
treatment will my vet propose?

A1.5.
Options your vet may discuss include:

diet change
(typically
to Hill's W/D, Hill's M/D, or Purina DM
formula, but
see Q2.3 and Q2.5 for
further discussion of diet issues)

treatment at home
with
insulin injections (note: insulin cannot
be given in pill form)

If insulin treatment is
elected, the type of insulin and the dose are
important choices. Generally, the dose should be low (1-2 units once or
twice a day) to begin with, increasing
gradually if needed. Your vet should explain the risks and
benefits of each choice, and will recommend a protocol that he/she
feels will work best for your individual cat. You should feel
comfortable asking your vet to discuss with you the rationale for the
recommended treatment. A list of good
questions to ask your vet can be found at Pets
with
Diabetes.

There is no consensus
here
on whether an otherwise healthy diabetic
cat needs to be routinely hospitalized. Hospitalization is
necessary if the cat is suffering from ketoacidosis, and is probably a
good idea if the cat is extremely dehydrated or has a very high blood
glucose (for example, more than 600 mg/dl or 33 mmol/L). Many
vets prefer to keep the cat for a day or two to observe how he responds
to the insulin, but some will teach you how to give the shot and ask
you to bring your cat in
the next day for another glucose reading. Some of this may depend
on your own comfort level and your vet's perception of your ability to
manage at home in the early days. If you already have some
medical background or experience with diabetes, you may feel ready to
jump
right in to treating your cat. On the other hand, if you
find the whole experience completely overwhelming, you may prefer
for your vet to get things started for you. In general, however,
your vet does not need to keep an otherwise healthy cat for more than a
few days, and regulation of blood glucose levels is not likely to take
place in the clinic.

The FDMB in general
recommends a conservative approach to regulation
and dosage adjustment. You may find your vet's treatment to be
similar or more aggressive; however we do not recommend frequent
increases each week or large dosage increases for any cat. All
increases should be based on an analysis of blood glucose readings
taken on the current dosage; this means that the pre-injection blood
glucose, the lowest blood glucose, and the duration of insulin activity
all need to be taken into account.

Q1.6. What is the
goal of treatment?

A1.6. The
overall goal is a happy and healthy cat with a normal
lifespan. Ideally, this is achieved by using diet and insulin
(and possibly drugs and exercise) to get your cat's blood glucose as
close as possible to normal glucose values (under 120 mg/dl or 6.7
mmol/L) without ever descending into unsafe hypoglycemic levels
(under 40 mg/dl or 2.2 mmol/L). For some cats,
particularly that lucky minority that can be controlled with a
low-carbohydrate diet alone, normal blood glucose values are attainable
("normalization"). Most other cats, particularly those who
do not respond consistently to food and insulin, or those who have
health problems which interfere with their ability to get to
near-normal blood glucose values, may need to be kept at higher overall
blood glucose values in order to avoid the
risk of hypoglycemia. For these cats, a more realistic goal is
"regulation," see Section 6.

Q1.7. Where can I
find a vet who is knowledgeable about
diabetes?

A1.7. Your
best bet is probably to get referrals from other
people in your area who are happy with their vet's treatment of their
diabetic cat. See also Debra & Care Bear's page on what to look
for when interviewing a vet.

Q1.8. How can I
find other people with diabetic cats in my
area?

A1.8.
You can
find a list of current members, carefully compiled by Carol &
Charlie,
at FelineDiabetes.com.
You may also post a message to the Feline Diabetes Message Board; be
sure to include your approximate area in the title of
the post, since not everyone reads every post. And be sure check
the registry at Gorbzilla's Sugarcat
Member Directory.

Q1.9. I can't
afford to treat my cat. What should I
do?

A1.9. A
diabetic cat must be treated; otherwise he will
essentially starve to death, which is a cruel way to die. But the
good news is that home care can substantially reduce costs. If after reading our money-saving tips, you
still believe you will not be able to afford the cost of caring for a
diabetic cat, please do not hesitate to post your concerns to the Feline Diabetes Message
Board. Someone may be able to help you. DON'T GIVE UP ON YOUR
SUGARCAT.

2.
ADDITIONAL TREATMENT

Q2.1. Can I give
oral medication instead of insulin?

A2.1.
Possibly. You should discuss this with your vet. Oral
medications
such as glipizide
or glyburide
will allegedly work for about 30%
of diabetic cats. However,
because these drugs can cause liver damage (and even further damage to
the
pancreas), and because giving an injection is often easier than giving
a pill, most people on this board prefer insulin. Several people
who switched to insulin after
using drugs have reported that they thought the oral medication
only delayed regulation. Others believe that starting with drugs
rather than insulin made it impossible for their cats' diabetes to be
controlled with changes in diet alone. Another drug, acarbose, works
by blocking or delaying the absorption of carbohydrates from
food. It probably is not necessary for a cat who is on a
low-carbohydrate diet.

Oral medications are not
a
good idea
for cats with elevated liver values (due to the possibility of
liver damage), or ketoacidosis or neuropathy (due to the need to bring
glucose levels down immediately). See the Pets
with Diabetes
site for a more detailed explanation. If
your cat shows uncharacteristic lack of appetite, vomiting, lethargy or
jaundice, discontinue the medicine and call your vet.
You should also have liver enzymes monitored frequently during the
early months.

Q2.2. Can I
control this with herbs or something instead of
insulin?

A2.2. If
your cat needs insulin, then you must give it to
her. If you're interested in an alternative approach, your best
bet is to
find a holistic
veterinarian who is familiar with treating diabetic cats.
A holistic vet will take a "whole animal" approach to see if there is
any way to strengthen the entire system, using diet, vitamins &
minerals, herbs, homeopathy, glandular supplements, Chinese medicine,
or whatever approach the vet is personally familiar with. A good
vet will keep your cat on insulin until and unless it is no longer
needed. For more ideas, read
the Holisticat
page
on diabetes, but keep in mind that there often
is not a lot of research on these approaches.

Q2.3.
What should I feed my cat?

A2.3. This
is the topic of numerous debates and discussions here,
partly because the scientific research is limited. Here are some
general principles:

If a cat currently
has
other health problems such as kidney
insufficiency or chronic renal failure (CRF), pancreatitis, liver
disease, bowel trouble, or urinary crystals, the diet must be primarily
based on these considerations and secondarily on the diabetes.

It is necessary to
feed a consistent diet at consistent times in order to keep blood
glucose within a predictable range, because blood glucose is closely
related to the amount and composition of
the most recent meal.

When changing a
cat's diet, it's necessary to change
gradually
and monitor glucose levels very closely, so that the proper amount of
insulin is being given at all times. Too much
insulin can kill your cat very quickly.

Most vets
follow one of two basic approaches to
diet for
diabetic cats: 1.) moderate-protein, low-carbohydrate, or 2.)
high-carbohydrate, low-fat, high fiber. Diabetic cats have been
regulated on each
type of diet, as well as regular cat food, and what works for one cat
may
be less than ideal for another.

A diet
moderate in protein and low in
carbohydrateshas
been used with great success by
many
owners of diabetic cats, who have found that this approach can reduce
their cat's
insulin requirements, or, in a minority
of cases, even eliminate the need for injected insulin for
long periods of time. This diet may be appropriate for a cat who
is otherwise healthy and who will eat canned cat food. Vets
using this approach may prescribe Purina
DM or Hill's M/D or may recommend canned kitten food. You can
also
duplicate this diet using high-quality commercial foods with similar
nutrient composition, see below. The low-carbohydrate diet may
not be appropriate for cats who are currently suffering from any of the
health conditions listed above. Discuss your cat's most recent
bloodwork with your vet to be certain that the higher protein, fat,
and/or phosphorus levels commonly found in this diet are appropriate
for your cat's
condition. Purina DM dry is high in sodium, which may not be
appropriate for cats with cardiovascular problems. If your cat
has a past history of any of these conditions, please consult your vet
for specific recommendations.

An older
approach, which is no longer popular
at the FDMB, is to feed the cat a diet fairly high in
carbohydrates and low in fat, with extra soluble fiber added to
slow the
conversion of starch to glucose. Vets using this approach recommend
Hill's W/D, a high-carbohydrate, high-fiber prescription cat food which
is designed for weight maintenance. (Other similar foods are
Hill's R/D, Purina OM, and various hairball formulas sold by Hill's and
Iams, see
below.) If your cat needs to
gain weight, a high-fiber diet may not be the best approach. If
your vet recommends this diet for your cat, do not hesitate to ask him
or her to explain the advantages and disadvantages of the two dietary
approaches.

Some people prepare food
at home; these diets can be high or low in
carbohydrates depending on whether grains are included in the
recipes. Further sources of information can be found in Dr. Strombeck's
Home-Prepared Dog and Cat Diets, the Holisticat raw food page,
Feline Future, and
Dr. Lisa's Feeding
Your Cat page. Additional sources for
recipes are Dr. Pitcairn's Complete Guide to Natural Health for
Dogs and Cats and The New Natural Cat : A Complete Guide for
Finicky Owners by Anitra Frazier. Some recipes
may contain grain, which many people consider to be inappropriate for
cats in general and diabetic cats in particular, so
you may want to reduce or eliminate the grain content. If you wish
to include grains, pearl barley and rice are both considered good
possibilities
(barley has a low glycemic index; rice is thought to be digested
more completely), but corn should be avoided because many cats are
allergic or sensitive to it. Don't simply feed meat, poultry or
fish by themselves, though, because such a diet is nutritionally
inadequate.

For details on the
protein, fat, and carbohydrate content of various
commercial foods, see the FDMB.

Q2.4. Can I
free-feed my cat?

A2.4.
Generally, you want your cat to eat around the time he
receives his insulin injections. Some people have set meal times,
and others use free-feeding. Still others put down food at meal
times only, but let the cat eat at his leisure. Insulin type is
an important factor in this decision. Short-acting insulins, such
as N (NPH), can be dangerous if the cat has not had a solid meal about
half an hour or so before the shot; on the
other hand, a cat on a long-acting insulin such as Lantus (insulin
glargine) or
PZI can follow a "grazing" schedule much more safely. Most people
here would agree that feeding a cat between the time insulin peaks and
the next shot is unwise, although a small high-protein,
zero-carbohydrate snack such as chicken or tuna should not
substantially affect blood glucose. Whatever you decide, be
consistent.

Q2.5
My cat doesn't like / I can't
afford the expensive prescription food. Is there any less expensive
substitute?

A2.5 Yes.
The idea that a diabetic cat must have
prescription food
is misguided (to say the least), and many people prefer to feed
commercial or home-made foods because they are cheaper, or have
higher-quality ingredients, or are preferred by their cats.
However, diet can affect
insulin requirements, so changes to an existing dietary regimen have to
be done carefully for a cat who is already on insulin or pills.
As mentioned above, you should ask your vet
if your cat has other medical conditions that need to be addressed with
diet.

If you're feeding canned
Purina DM, you can substitute any
canned cat food which has a similar level of carbohydrate (no more than
10-12% of calories -- mixed with: 1.) a low-fat source of high-quality
protein (chicken, turkey, lean beef, egg, the occasional bit of cooked
seafood) equal to no more than 20% of the total calories, and 2.)
(optionally) 50-100 IU of
vitamin E per day. Keep in mind that this diet may not be
appropriate for cats with kidney disease.

If you're feeding dry
Purina DM or dry Hills M/D,
check out Innova
EVO Cat & Kitten, which has about 6% of calories from
carbohydrate (warning for guardians of cats with kidney disease: it is
somewhat high in phosphorus).

If you're feeding dry
Science Diet W/D, any dry food with a
similar fiber level will do the trick. If you're feeding canned
Science Diet W/D, Science Diet
Feline
Light is similar, or you can feed any good quality canned cat food and
add
extra fiber in the form of psyllium (1/4 teaspoon mixed with 1
tablespoon
water) or canned unsweetened pumpkin (1 tablespoon). Check the food tables to make
sure the levels of other nutrients, particularly carbohydrate are
similar;
otherwise, you must make the switch slowly, over a
period of several weeks, and monitor your cat's
glucose levels carefully. Changing
the diet without changing the insulin dose can result in brain damage
or death from hypoglycemia -- be cautious!

In all cases,
home-cooking
is always an option, so don't feel that
you're doomed to feed commercial foods.

The easiest way to give
vitamin E is to buy it in liquid form in a
bottle or in powder (water-soluble) form in a gelatin capsule (which
can be opened and closed). Another option is to buy the regular
400 IU capsules for humans, and mix
the contents of one with the food once or twice a week.
Experiment to find out what's palatable to your cat. The
d-alpha (natural) form is more potent than the dl-alpha
(synthetic) form, and if it contains extra selenium, or mixed
tocopherols and tocotrienols, so much the better.

Q2.6. How much should I feed my cat?

A2.6. As
many calories as your cat needs to maintain a healthy
weight; typically 15-25 calories per pound of ideal weight, depending
on your cat's activity level. Cats who require fewer calories
may benefit from more nutrient-dense foods so that they do not develop
nutritional deficiencies. Unregulated cats may require more food
at first because they are not able to properly metabolize what they are
eating.

3.
INSULIN

Q3.1. What kinds
of insulin are there?

A3.1.
Insulin comes
in all sorts of varieties. Some are human insulins, and some are
animal insulins, usually beef or pork. Some have fairly short durations
(N, NPH, Novolin Insulatard), some medium (Lente (now discontinued),
Caninsulin, Novolin
Monotard (now discontinued)), and some animal-based NPH), and some long
(Ultralente (now discontinued),
Novolin Ultratard (now discontinued), PZI, Lantus (insulin glargine),
and Levemir (insulin detemir)). For more
information, see the Pets
with Diabetes page. We
strongly recommend that you avoid using a short duration
insulin as your first
insulin, because of the significant risk of hypoglycemia.
If your cat does not respond well to the human insulins, many
cats here have obtained excellent results from beef insulin (which is
closer biochemically to feline insulin), most notably the PZI
duration. For
cats who do better with beef insulin but have problems with the PZI
lasting too long, Beef Lente (also known as UK
Lente) is available from the Wellington Pharmacy in London.

Q3.2. Where can I
get PZI insulin?

A3.2. For
lots of good details on where to find PZI, see the PZI page
at the Feline Diabetes website. Be aware that not all PZI formulas
are beef- or pork-based; most people who switch to PZI do so
because human insulin is not working for their cat, so be sure to
ask!
The Professional Arts Pharmacy in Baltimore only compounds human
insulin,
for example.

Q3.3. What can I
expect to pay for PZI insulin?

A3.3. UK
PZI is currently $63 per bottle (U-100) plus $50
shipping for up to
25 bottles; Blue Ridge is around $60 (U-40, which is
much more dilute; minimum order 3 bottles), but your vet may mark up
the price. BCP is $58 per bottle (U-100) plus $10 shipping
(Fed-Ex overnight). Summit is CDN$25
per 5 ml bottle (U-100) plus $5 shipping, next-day delivery.

Q3.4. What kind
of syringe should I use?

A3.4. Most
people here have been satisfied with BD Ultra-fine
U100 3/10 cc, Monoject Ultra Comfort (available from diabeticpromotions.com),
or Walmart ReliOn Ultra Comfort. The latter two measure
half-units, are manufactured by the same company with different
branding, and are less expensive than B-Ds, with ReliOns being less
expensive than the Monojects. Get the finest needle possible,
which is 31 gauge. Some people have difficulty with the longer
(1/2 inch) needles and recommend the 3/8 inch needles to avoid shooting
"through the tent"; others experience the opposite problem with shorter
needles not delivering the insulin properly, so experiment to find out
what's right for your cat. If you're giving a U-40 insulin,
either use the appropriate syringe, or use a conversion
factor for giving U-40 insulin in a U-100 syringe.

Q3.5. Do I need a
prescription for insulin or syringes?

A3.5.
Probably not. Check the chart at the Children with
Diabetes site for more information on your state or
country. But even if your state requires a prescription, you may
still be able to get supplies via mail order.

Q3.6. Can I reuse
syringes?

A3.6.
Although some
people do reuse (generally not more than once), most
people here recommend against it. After the first injection, the
needle is no longer sterile, (which can contaminate the insulin and
promote infection in the cat), and the coating is degraded. Take
a look at the picture
of a reused needle and decide for yourself. If cost is
an issue, try a generic brand.

Q3.7. How do I
dispose of used needles?

A3.7. Laws
vary from one location to the next, and your vet or
local waste removal facility should be able to give you appropriate
advice. Some vets will dispose of the needles for you. The
safest way to keep them until disposal is to get a strong plastic
"sharps" container which you can purchase at your pharmacy. You
may also want to buy a clipper so that you can dispose of
the needle separately from the syringe.

Q3.8. My cat
hates getting his shot. Now what?

A3.8. Make
sure you're using the thinnest possible needle -- 31
gauge is the thinnest, and 30 gauge is usually acceptable, but many
people report success with 29 gauge. You also need to make sure
you aren't hitting a muscle; the insulin is supposed to be deposited
under the skin. To brush up on your injection techniques, and
learn new techniques, check out Feline Diabetes,
Pet
Diabetes,
the Auburn
University page, and Jamie's
explanation.

Q3.9. How long
does a bottle of insulin last?

A3.9.
Unopened insulin is good until the expiration date when
handled gently, stored at the manufacturer's recommended temperature
range (36º to 46º F for Humulin vials), and kept covered from
light. However, an insulin bottle which has been used, will need to be
replaced before the expiration date. There are several reasons for
this, including exposure to possible contaminants when the rubber seal
is punctured, exposure to oxygen, and imperfect mixing (which may
change the concentration of the insulin, even when care is taken to mix
well). Because of this, it's always a
good idea to inspect your insulin. Material settled on the bottom
after mixing, or clumps, indicate potential problems.

Eli Lilly, the
manufacturer of Humulin insulin, recommends
replacing Humulin vials within 28 days after
opening. Many people on the FDMB view this recommendation
as overly conservative for single-user vials, and have
found that Humulin is often good for somewhat longer. Some people on
this board do replace Humulin vials every 4 weeks. Others
replace every 6 weeks, every 8 weeks, or when they notice reduced
glucose control.

Lantus has mixed
reviews,
with some people observing that it doesn't
last more than a month, and others getting greater usage from it.
A pack of 5 3-ml cartridges may be more cost-effective than the 10 ml
vial, even though the up-front expense is higher.

The consensus on the board
is that animal-source PZI (protamine zinc
insulin) lasts longer than Humulin insulin. Many people here use PZI
until the bottle is empty. PZI which has been diluted with sterile
saline solution by a vet, pharmacist, or consumer should be replaced
every 30 days.

Q3.10. Sometimes
I can't be home to give one of my cat's shots; is it okay to give it
late or early?

A3.10.In general, you
should
keep on a schedule for giving injections. If you give the shot once a
day, do it
at the same time every day. If you give shots twice a day, do it
at the same time twelve hours apart. However, occasionally giving
insulin an hour earlier or later isn't likely to cause any trouble. If
you need to vary the timing by more than this, it may be prudent
to give a reduced dose (at the previous shot if you need to shoot
early, and at the current shot if you need to shoot late). If your
schedule never permits you to shoot 12 hours apart, you may need to
experiment with different morning and evening doses, or even use
different types of insulin for the morning and evening shots; however,
you'll need to hometest your cat's blood glucose to determine a safe
approach.

Q3.11. How much insulin
should my cat be getting?

A3.11. As
much as he needs to keep him regulated.
This could be anywhere from 1/4 unit to 10 units twice a day (or
even more for cats with rare health conditions such as Cushing's
disease
or acromegaly.)
A survey once carried out on the FDMB suggested that most cats will not
need
more than 4 units twice a day if on a low-carbohydrate diet or 8 units
twice a day if on a high-carbohydrate diet. The Cornell
Feline Center recommends that "Cats requiring excessively high
insulin doses (greater than one to two units of insulin per pound per
day) should be evaluated further."

Secondarily, you can
monitor your cat's urine, which will tell you
if
glucose is high at some point during the day, but will not tell you if
your
cat is getting too much insulin and the blood glucose level is dropping
dangerously low. One very good method for monitoring a cat who is
not being hometested besides urine strips is to keep track of the
amount of water being consumed; increased consumption usually means
that blood glucose is too high. Finally, you should watch your
cat for unusual attributes, such as excessive urination, rough
coat, or dilated pupils, and learn what this tells you about your
individual cat's glucose levels.

Q4.2. What kind
of glucometer should I get?

A4.2. Most
of the regulars here use either the Bayer/Ascensia
Elite or Elite XL (but see the caution below), LifeScan OneTouch Ultra,
or AccuChek Advantage with only the Comfort Curve strips.
A newer model requiring even less blood, the TheraSense Freestyle,
appeared promising at first, but our experience is that it can
substantially underestimate
blood glucose values (if you already own one, don't panic, but be
aware of this problem). You want a model that only requires a small
amount of blood (2-3 microliters) and which has "sipping" action; it
may cost a little more, but it will make your life tremendously
easier. One online source of glucometers which has good prices is
diabeticpromotions.com,
and another is hocks.com.
You can also get the glucometer at pharmacies, Walmart, Costco, or any
similar store. There's often a rebate coupon included.
Occasionally, you can even get
a meter free if you buy 100 test strips.

Caution on Bayer
Ascencia
Elite meter: The Bayer Elite is generally
a good
meter, but it has the bad habit of beeping before the strip is filled
with blood, leading people to withdraw the strip prematurely and obtain
a false low value. See Terry's graphic
of how full the strip should be for a reliable reading.

Q4.3. How often should my cat's
glucose levels be tested?

A4.3. As often as is
convenient for both
of you. Many people test before every single shot, usually because past
experience with hypoglycemia has made them cautious. Some people do
sporadic testing, but run a curve every
couple of weeks (or less often
if the cat is regulated). If you choose
to do this, the best times to check are right before the shot and
around the time that glucose reaches its low point, typically from 4 to
6 hours post-shot. Some people only test if something is
clearly wrong (for example, strange behavior, lethargy, or increased
urination) and they need to know what the problem is.

Q4.4. My cat's
pre-shot level was way below the usual
value. Should I give the injection?

A4.4.
There's no hard and fast rule, but if you don't have data
on how your
cat responds to insulin, here are some general guidelines. Below
150 mg/dl (8.3 mmol/L), don't give insulin. Between 150 and 200
(8.3-11.1 mmol/L), you have three options:
a.) give nothing; b.) give a token dose (10-25% of the usual dose); c.)
feed as usual, test in a couple of hours, and make
a decision based on that value. Above 200 (11.1 mmol/L) but
below the cat's normal pre-shot value, a reduced dose might be
wise. In all cases, if you are reducing or eliminating
insulin, it's wise to check for ketones in the
urine. Above the normal pre-shot value, give the usual dose,
but if the pre-shot value is consistently elevated, it's a good idea to
schedule a full glucose curve to see whether a change in dose or
insulin is appropriate. In most cases, the target "peak" value should
not be below
100 mg/dl (5.6 mmol/L), and for some cats it might be higher.
Keep in mind that these are general guidelines, and they should be
personalized to your own cat's reactions to insulin. If your
experience is that your cat does not became hypoglycemic with a dose
which is close to her usual, then your experience should be your guide.

Q4.5. I'm not from the United States, and I don't understand your
units of measurement. My cat couldn't have a blood glucose of 300
even if you soaked her in honey for a week.

A4.5.
Americans have only recently switched from the traditional
scruples/quart to the metric mg/dl. While we were busy patting
ourselves on the back for being sophisticated, the remainder of the
world moved on to the international system (SI) and now measures blood
glucose in mmol/L. Just divide the American values by
18 to see what's really going on.

Q4.6. I'm
following the instructions faithfully, but I
still
can't get blood from my cat's ear.

A4.6. In
addition to the excellent tips in the above links, here
are some extra suggestions:

Jerri & Opie's
Rice
Sock: Warm the ear using a sock filled
with uncooked regular rice,
barley or oatmeal which has been warmed in the microwave (test on wrist
to
ensure it's not too hot).

Alternatively, use
a small jar filled with hot water - kitty's ear may
fit neatly around this curve, or a ziploc baggie with wet paper towel
inside warmed in the microwave, or a heat lamp behind the cat's ear to
keep it warm (not too close!).

Or just massage the
ear a bit to get the blood flowing.

Hold something solid
against the back of the ear to hold it in
place. (A flashlight can serve double-duty here.)

Get as close to the
edge of the ear as possible.

If using a lancet
device, use the middle depth setting on the
lancet device if adjustable. You can adjust depth up or down as needed
with experience - you do not want to pierce through the ear although
this is not harmful.

Hold lancet device firmly
against the ear.

If doing a manual
ear
prick, be sure to prick the ear at a
shallow (45-degree) angle, not straight down.

Fold the ear over
the
wound, or pinch the ear gently on either
side, to help the blood well up.

If the drop is not
forming properly, gently "milk" the ear on either side
of the prick by stroking towards the prick, bringing the blood to that
area.

You may attempt to
add more warmth to increase size of blood drop depending
on your heating method.

Sometimes it helps
to
make 2 pricks side by side one after the
other to ensure you get enough blood from one or both.

Try using the other
ear.

To prevent bruising,
apply firm pressure on the ear prick with a
tissue while waiting for the meter to count down.

Be sure to give your cat
a hug and/or a treat afterward to reinforce the idea
that this can be a pleasant experience!

Q4.7. My cat has
been off of insulin for several days, and
I'm getting glucose readings in the 40s and 50s (2.2-3.3 mmol/L).
Should I treat him for hypoglycemia?

A4.7.
Congratulations! As long as you're sure your meter
readings are based on full test strips, then it looks like your cat is
on a honeymoon. Although lab printouts indicate that 70-120
mg/dL (4-7 mmol/L) is normal, we have observed that non-diabetic cats
can typically have lower values on our meters. As long as your
cat is not showing any symptoms of hypoglycemia or signs of distress,
all is well. You might want to monitor his blood glucose values
for the next week or so; after that, occasionally monitor his blood and
urine for glucose. Also, you need to keep a close
eye on his drinking habits and general health, because it's always
possible that this is temporary. In the meantime, enjoy!

Q4.8.
Are there other signs besides
blood glucose that I can monitor at home?

A4.8.
There's no substitute for knowing
your cat's blood
glucose. But it's always a good idea to keep the "whole cat" in
mind. Signs that your cat may not be getting
enough insulin include excessive urination, high glucose in
urine (although for some cats it's always high), weight loss,
lethargy, depression, dull or dry fur, dandruff, lameness (may indicate
neuropathy), and change in pupil size (for some cats). Signs that
your cat may be getting too much insulin include
all the symptoms
of hypoglycemia, sleepiness or lethargy an
hour or two after receiving insulin, all the symptoms just mentioned
for hyperglycemia (if he is suffering from chronic
rebound),
and little or no glucose in the urine. Signs that your cat is
doing well include the 5 P's [purring, playing, peeing (normally),
pooping (ditto), and preening], as well as
normal appetite and thirst.

Q4.9.
I'm interested in home-testing,
but my vet won't let me. What should I do?

A5.1.
Ketones are a
source of fuel manufactured from fatty acids by the
liver and utilized by the body when glucose is unavailable due to a
lack of insulin or glucose supply.

Q5.2. How often
should I test for ketones?

A5.2. If
your cat is well-regulated and behaving normally, test
for ketones on an occasional basis. However, if your cat has been
refusing to eat or seems ill, you should test for ketones as soon
as possible. Ketone testing should be part of standard diabetic
care.

Q5.3. How do I
test for ketones?

A5.3.
Ketones are tested in the urine using Keto-stix (R) or
Keto-diastix (R), which you should be able to buy in the diabetic
supplies section of your local pharmacy. If you can catch your
cat on the litter box, you can either hold the end of the stick in the
urine stream, or collect the urine in a small paper cup and dip the
stick in (for a female cat, a deep plastic ladle kept by the litter box
may be helpful for urine collection). If
you see any signs of ketones, contact your vet right away.

Q5.4. How are
positive ketone readings usually treated?

A5.4. The
remedy depends on the reason ketones appear but it will
either involve feeding more food to anorexic kitties, a switch to a 2
injection schedule, a longer duration insulin or a higher insulin
dosage or a combination of any of the above.

Q5.5. What is
Diabetic Ketoacidosis?

A5.5. Diabetic
ketoacidosis is a life threatening condition caused by an
accrual of too many ketones in the bloodstream altering the pH and
blood chemistry. As the condition worsens, dehydration, anorexia
and vomiting usually appear. If untreated, seizures and then
death occur. Crisis treatment includes restoration of the blood
chemistry through hydration and electolyte replacement and returning
the main fuel source back from ketones to glucose by using small doses
of fast acting insulin and a glucose drip.

6.
REGULATION

Q6.1. What is
regulation?

A6.1. There
are different definitions of regulation. As
hometesting becomes more common, we've been getting a better
understanding of what cats and their humans might be capable of.
Janet & Fitzgerald propose the following "regulation
continuum":

There may also be an extra
category of "mostly above 300 (16.7) but
with good clinical signs" which occurs with some cats who are getting
insulin. We don't know why it happens, but such a cat probably
should not be considered to be regulated. On the other end of the
spectrum, it is possible for a cat who is not getting insulin to have
blood glucose as low as 40 mg/dl (2.2 mmol/L) on a home glucometer.
If you have a non-diabetic cat, try testing her with the same
meter to get a safe comparison figure.

Q6.2. Which
definition of regulation should be my goal?

A6.2. That
depends on your individual situation. Generally,
it's thought that a cat will suffer less long-term organ and nerve
damage if his average blood glucose is lower rather than higher.
However, because preventing hypoglycemia is a top priority, it
may not be practical to try for normal numbers. The ability of
your cat to respond to food and insulin in a consistent manner and your
own ability to monitor your cat are both important factors in
setting your goal. For most cats who are receiving insulin,
"regulated"
is a reasonable first goal, after which you can try for
"well-regulated". For the lucky minority who can be
diet-controlled, normalization is
often achievable. It’s important to realize that some cats never
consistently stay in regulation range in spite of all efforts, and yet
they can be happy and healthy anyway. Ultimately, you should
tailor your goals to your cat's individual situation, and you should
always consider your cat's quality of life as well as the numbers as
you evaluate how well your treatment protocol is working.

Q6.3. How do I
achieve regulation?

A6.3. We recommend
following a
systematic
protocol, the “Start
Low & Go Slow Approach”. This method has been tested and
improved by hundreds of members of the Feline Diabetes Message Board
over the years, and it typically produces improved blood glucose
control, without risking rebound or hypoglycemia.

Q6.4. My cat has been on insulin for a while and her diabetes
is still out of control. Why can’t I regulate her?

A6.4.
The most common causes for poor control of blood sugar are:

Somogyi
rebound from too much insulin-- especially if the insulin was
started at more than 2 units twice per day, and/or was increased more
frequently than 0.5 unit every 7 days. In some cats, rebound
occurs at normal or high blood sugar levels, keeping blood glucose
levels high all the time. For more on Somogyi rebound, see Gorbzilla's
mini-FAQ and Steve & Jock's Wikipedia
page.

Wrong
insulin type for your
cat (especially Humulin 70/30 or Humulin N (NPH), which
don’t last long enough for many cats).

Wrong
insulin schedule for your cat (most
commonly, shots once per day when the
cat needs them twice per day).

Not
enough insulin -- the insulin dose
needs to be increased, slowly and cautiously.

Other
medical
issues (such as insulin resistance,
acromegaly, and Cushing’s disease / hyperadrenocorticism) may also
cause obstacles to regulation. These problems are relatively uncommon,
and should not be prime suspects until
the more common causes have been ruled out. More details
can be found at The
Hard-to-Regulate Pet.

If a previously regulated
cat suddenly starts showing poor response to
insulin, two likely reasons are infection and loss of potency of
insulin.

Q6.5. What is tight regulation?

A6.5. Tight
regulation refers to using insulin to keep a diabetic
cat's blood glucose levels within normal or near-normal ranges as much
of the time as possible. This approach to regulation is very
controversial because of the high perceived risk of hypoglycemia.
However, it is not merely an exercise in vanity; keeping blood
glucose in this range is thought to reduce long-term damage to the
organs and nerves. Additionally, some people believe that
diabetic cats kept in or near a normal glucose range have a higher
chance of achieving diabetic remission, especially if so controlled
during their first year after diagnosis. (An alternative
explanation, though, is that the cats who achieved remission might have
done so under almost any insulin regimen as long as they were fed a
low-carbohydrate diet.) The downsides are that heavy monitoring
is often required, and that some cats simply cannot be tightly
regulated no matter how hard the human tries. If you are
interested in this technique, the Feline Diabetes Message
Board has a special forum for
discussing it.

Q6.6. Is
remission possible?

A6.6. It is
possible for some diabetic cats to be controlled
without insulin. There is increasing anecdotal evidence that a
low-carbohydrate diet (5-10% of calories from carbohydrates) and
perhaps a short course of insulin can result in a cat whose diabetes
can be controlled by diet. However, this can't be guaranteed for
any specific cat. Our historical estimate is that about 1/3 to
1/2 of newly-diagnosed cats may respond this way, and whether your cat
belongs to this group is a matter of luck. There is also preliminary
evidence which suggests that this rate may be higher in cats who
are given Lantus (insulin glargine). Remission is also possible for
steroid-induced diabetics; in some of these cats, pancreatic function
resumes over time.

Q6.7. I just
can't get my cat's glucose into regulation
range -- is he doomed?

A6.7. Not
necessarily. Your cat may benefit from a
different approach besides the standard twice-a-day fixed dosing.

7.
OTHER PROBLEMS

Q7.1. My cat is
walking funny / weak in the hind legs / not
jumping well. Is this related?

A7.1. There
is a condition common in diabetic cats called peripheral
neuropathy, which causes weakness in the hind legs.
Symptoms include: weak hind legs; feet slipping out from under him/her
on the floor; walking down on the hocks in back and/or on the wrists in
front; lying down more frequently, especially after short
walks If your cat has this condition, it is a sign the
cat's blood glucose is still too high, which is causing nerve damage.
Improved regulation is the best way to reduce neuropathy, but check out
Laurie & Jasper's
page
for additional treatment options using oral methylcobalamin (a form of
vitamin B-12), and Jason
& Mr. Kitts' research on using injectable
methylcobalamin. This is
useful as an adjunct to good regulation, but should not be considered a
substitute. (The Life
Extension
Foundation also has some interesting supplement ideas.)
In
the meantime, Vesla & Blondie suggest using Shaw's Paw Wax to
help
your cat get traction on slippery floors. Throw rugs will also give
your
cat places to stop and rest while trying to get around.

If you suspect your cat
has neuropathy, please get a formal
diagnosis; a cat can show some of these symptoms but have other
problems such as arthritis or potassium depletion. If your cat is
wobbly and walking in circles or erratically, you may be dealing with a
hypoglycemic episode, in which case go immediately to question
1.4. If your cat can't
walk at all, or has his head tilted, get him to the vet immediately.

A7.4. It
depends on
how long this situation has been going on. If
it's just one or two meals, it's probably not a serious
situation. Your cat may have a hairball or a minor
infection. Try to tempt him to eat something tasty (see next
paragraph), reduce his insulin to compensate for the reduction in
intake, and check for ketones as soon as you have the opportunity (see
Q6.3 above).

If a diabetic cat
persistently refuses to eat, this is a very
serious
situation and should not be ignored. First, you need to verify
whether
your cat will eat absolutely nothing, or just won't eat the food that
you've
offered. Try a variety of tempting dishes. Your cat may be
suffering
from a poor sense of smell, so dishes which are very fragrant (such as
tuna
or liver), or heated up, may excite some interest. Alternatively,
your
cat may prefer something bland like Hill's A/D (a prescription food) or
baby
food (meat flavors are best; make sure there are no onions or garlic
added). Sometimes, a cat will not eat from a dish but will eat
from your hand. Although eventually you need to feed your cat the
most healthful diet, getting food into your cat is the most important
thing in this situation, so feed whatever he'll eat.

If
your
cat won't eat anything at all,
contact your vet.
Persistent lack of appetite can
result from a variety of causes, including respiratory or urinary tract
infection, pancreatitis,
hepatic lipidosis,
or even more serious conditions (including intestinal blockage).
Be alert for vomiting or signs
of nausea (such as excessive salivating or lip-licking). You
should also test for ketones (see Q5.3) as soon
as you have the opportunity, because ketones can cause lack of
appetite. Get your cat to the vet
immediately if you detect ketones in his urine, or if his urine or
breath smell fruity or like acetone.

Your vet may recommend
syringe-feeding. Sometimes, if you put some
food in the cat's mouth by hand (behind the teeth is fine), this will
be enough to jump-start his appetite a little. If this doesn't work,
buy an oral syringe (usually in the
baby supplies at the grocery or pharmacy). Dilute a smooth food
such as baby food with a little water and put it into the syringe (it
may help to pack it from the top and shake it down). Put the
syringe in his mouth, sideways, behind her back teeth, and slowly
deliver the food (give him time to swallow!). Give the cat as
much as he will eat, but don't force too much, because he may not be
able to tolerate more than a tablespoon or so of
food at a time. Many small feedings may be necessary. If
all else fails, your vet may need to prescribe appetite stimulants or
even install a feeding tube (in the case of hepatic lipidosis).
For more ideas, see Louise &
Chorniy's syringe-feeding FAQ.

You may need to give a
reduced insulin dose or even skip a shot,
because blood glucose is related to food intake. However, it is
dangerous to skip many shots, because ketones may develop.
Monitoring your cat's blood glucose at
home can be very valuable in helping you and your vet make this
decision.

Note to
readers: This is an HTML document, and
most
of the useful information is contained in the links. If you are
reading a printed copy of this, you are not obtaining the full value of
the document. This document is copyright (C) 2000-2008. You
may freely copy and distribute the document, but you may not charge
money for it (not even handling costs), and altering the content is
prohibited, not to mention really rude to the people who have put so
much effort into this. The copyright includes the questions and
not just the answers. If you have corrections or
suggestions, please post them to the Feline Diabetes Message
Board (www.felinediabetes.com/terms.htm), and if the consensus
is that you have offered an improvement, the FAQ will be updated.

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